Integrating Poverty and Gender into Health Programmes

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Module on

HIV/AIDS

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Module on HIV/AIDS

www.wpro.who.int

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Health programmes.

ISBN 13 978 92 9061 388 6 (NLM Classiﬁcation: WA 30 )

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ACKNOWLEDGEMENTS

This module is one of a complete set entitled Integrating Poverty and Gender into Health Programmes:

A Sourcebook for Health Professionals. It was prepared by a team comprising Sarah Coll-Black, Elizabeth Lindsay (consultants and principal writers), Anjana Bhushan (Technical Officer, Health in Development) and Kathleen Fritsch (Regional Adviser in Nursing) at the World Health Organization’s Regional Office for the Western Pacific. Additional material was contributed by Ilia Smith. Breeda Hickey provided substantial supplementary inputs and also did preliminary editing of the module.

Bernard Fabre-Teste, Gaik Gui Ong and Nguyen Thi Thanh Thuy provided thoughtful comments and helpful inputs. Rhonda Vandeworp did the ﬁnal editing. Design and layout were done by Zando Escultura.

Table 4: HIV and AIDS statistics and features in the Paciﬁc 9

Table 5: Estimated number of people with HIV/AIDS in China 9

Table 6: Poverty, low education and risk-taking behaviour in Viet Nam 16 Table 7: Estimated number of people receiving and needing antiretroviral therapy and the

percentage coverage in low- and middle-income countries by region, June 2006 64

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ABBREVIATIONS

AIDS Acquired immunodeﬁciency syndrome ARI Acute respiratory infection

ART Antiretroviral treatment or therapy

ARV Antiretroviral

CEDAW Convention on the Elimination of All Forms of Discrimination against Women CRC Convention of the Rights of the Child

DFID Department for International Development of the United Kingdom FBO Faith-based organization

GDP Gross domestic product

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GHI Global health initiative

GNI Gross national income

GNP Gross national product

HIV Human immunodeﬁciency virus

ICW International Community of Women IDU Injecting drug user

IEC Information, education and communication MCH Maternal and child health

MDG Millennium Development Goal

MTCT Mother-to-child transmission

MSM Men who have sex with men

NGO Nongovernmental organization NTP National Tuberculosis Programme

OECD Organisation for Economic Co-operation and Development OI Opportunistic infection

OVC Orphans and vulnerable children PEP Post-exposure prophylaxis

PHC Primary health care

PLWH People living with HIV

PMTCT Prevention of mother-to-child transmission PRSP Poverty Reduction Strategy Paper

RBM Roll Back Malaria

RTI Reproductive tract infection

SIDA Swedish Agency for International Development Cooperation SRH Sexual and reproductive health

STI Sexually transmitted infection

TB Tuberculosis

UN United Nations

UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme

UNGASS United Nations General Assembly Special Session on HIV/AIDS UNHCHR United Nations High Commission for Human Rights

UNICEF United Nations Children’s Fund

UNIFEM United Nations Development Fund for Women VCT Voluntary counselling and testing

WB World Bank

WHO World Health Organization

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PREFACE

Over the past two to three decades, our understanding of poverty has broadened from a narrow focus on income and consumption to a multidimensional notion of education, health, social and political participation, personal security and freedom and environmental quality.¹ Thus, poverty encompasses not just low income, but lack of access to services, resources and skills; vulnerability; insecurity; and voicelessness and powerlessness. Multidimensional poverty is a determinant of health risks, health seeking behaviour, health care access and health outcomes.

As analyses of health outcomes become more reﬁned, it is increasingly apparent that the impressive gains in health experienced over recent decades are unevenly distributed. Aggregate indicators, whether at the global, regional or national level, often tend to mask striking variations in health outcomes between men and women, rich and poor, both across and within countries.

An estimated 70% of the world’s poor are women.² Similarly, in the Western Pacific Region, poverty often wears a woman’s face. Indicators of human poverty, including health indicators, often reflect severe gender-based disparities. In this way, gender inequality is a significant determinant of health outcomes in the Region, with women and girls often at a severe societal disadvantage.

Although poverty and gender signiﬁcantly inﬂuence health and socioeconomic development, health professionals are not always adequately prepared to address such issues in their work. This publication aims to improve the awareness, knowledge and skills of health professionals in the Region on poverty and gender concerns.

The modules that comprise this Sourcebook are intended for use in pre-service and in-service training of health professionals. This publication also is expected to be of use to health policy-makers and programme managers, either as a reference document or in conjunction with in-service training.

All modules in the series are linked, though each one can be used on a stand-alone basis if required. Two foundational modules establish the conceptual framework for the analysis of poverty and gender issues in health. Each of the other modules is intended for use in conjunction with these two foundational modules. The Sourcebook also contains a module on curricular integration to support health professional educational institutions integrate poverty and gender concerns into existing curricula.

All modules in the Sourcebook are designed for use through participatory learning methods that involve the learner, taking advantage of his or her experience and knowledge. Each module contains facilitators’

notes and suggested exercises to assist in this process.

It is hoped that the Sourcebook will prove useful in bringing greater attention to poverty and gender concerns in the design, implementation and monitoring and evaluation of health policies, programmes and interventions.

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Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals

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T

wenty-ﬁve years since the onslaught of the HIV/AIDS epidemic, the number of people infected with the virus continues to rise. Globally, 33.2 million people are living with HIV.³ In the Region, the epidemic is largely entrenched among marginalized populations, with at least one country, Papua New Guinea, experiencing a generalized epidemic. In some countries, the means of transmission are changing, often exploiting the vulnerability of women and young people to infection.

Experience increasingly shows that the socioeconomic factors contributing to the rapid spread of HIV in the Region include low education, limited access to health care services and increased mobility within and between countries—factors that are largely determined by poverty and gender inequality.⁴ For example, evidence from Cambodia and Viet Nam reveal a strong association between poverty and lack of education and an increased risk of infection.⁵ Gender inequality enhances the vulnerability of women, particularly young women, to HIV infection, as the rising rates of HIV among women worldwide attest. Evidence similarly shows that poverty and gender inequality can limit the access of poor men and women, boys and girls, to appropriate prevention, diagnosis, treatment and care for HIV/AIDS.

The growing commitment to curbing the HIV/

AIDS epidemic requires that health professionals

at the community, provincial, national and international level have the knowledge, skills and tools to more eﬀectively respond to the health needs of poor and marginalized people. The need for such knowledge and skills has become more pressing in face of the pledge to ensure universal access to prevention, treatment and care for HIV/

AIDS in the Region. However, many health professionals in the Region are not adequately prepared to address these issues.

This module is designed to improve the awareness, knowledge and skills of health professionals on the poverty- and gender-related dimensions of HIV/AIDS. It is divided into six sections:

Section 1

t provides a brief overview of the HIV/AIDS pandemic and an understanding of HIV and AIDS.

Section 2

t examines WHAT the links are between poverty, gender and HIV/AIDS.

Section 3

t discusses WHY it is important for health professionals to address HIV/AIDS, from eﬃciency, equity and human rights perspectives.

Section 4

t discusses HOW health

professionals can address poverty and gender concerns in HIV/AIDS.

Section 5

t provides notes for facilitators.

Section 6

t contains a collection of tools, resources and references to support health professionals in their work in this ﬁeld.

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The human immunodeficiency virus (HIV) compromises the human immune system and impedes its ability to fight infection. HIV leads to acquired immunodeficiency syndrome (AIDS). Through processes that are still not fully understood, HIV is able to infect key cells (CD4 cells) that coordinate the immune system’s fight against infection.⁶ This slowly leads to persistent, progressive and profound impairment of the immune system. When the body can no longer fight infection, it is said to have acquired the disease called AIDS. When a person with HIV is diagnosed as having AIDS, this means they have one or more of a defined list of otherwise usually rare illnesses or ‘opportunistic infections’

and conditions such as cancer.⁷ Opportunistic infections are infections that take advantage of the body’s weakened immune system.

The virus has two sub-types: HIV-1, the most common type found worldwide, and HIV-2, which is found mostly in West Africa. Both HIV-1 and HIV-2 have the same modes of transmission and are associated with similar opportunistic infections and AIDS.⁸ Blood tests or the appearance of certain opportunistic infections indicate that the infection has progressed from HIV to AIDS.⁹ Various treatment modalities and combinations of antiretroviral (ARV) therapies can reduce HIV progression and transmission (particularly from mother to child).

HIV transmission can be “horizontal” or “vertical”.

Horizontal transmission occurs through the following:

Sexual intercourse (vaginal, anal and oral) or 1.

through contact with infected blood, semen, or cervical and vaginal ﬂuids. This is the most frequent mode of transmission worldwide.

HIV can be transmitted from any infected person to his or her sexual partner (man to woman, woman to man, man to man, and woman to woman). The presence of other sexually transmitted infections (STIs) increases the risk of HIV transmission.

Blood transfusion or transfusion of blood 2.

products (e.g. those obtained from donor blood infected by HIV).

Injecting or skin-piercing equipment 3.

contaminated with HIV.

Vertical transmission occurs from mother to child during pregnancy, labour and delivery or through breast milk.

HIV cannot be transmitted by coughing or sneezing; handshakes; insect bites; work or school contact; touching, hugging or kissing; using toilets;

water or food; using telephones; swimming pools;

public baths; or sharing cups, glasses, plates and other eating, drinking or cooking utensils.

WHO clinical staging system for HIV infection and disease

As the use of antiretroviral therapy (ART) increases, surveillance of AIDS alone does not provide adequate information on the magnitude of the HIV epidemic. Information on adults and children with HIV infection is more useful for: estimating the treatment and care burden; planning for effective prevention and care efforts; and assessing care initiatives.¹⁰ In response, WHO recently revised the case definitions for surveillance of HIV and the clinical and immunological classification of HIV-related diseases. The case definition of HIV has been simplified and harmonized with the revised clinical staging and immunological classification that have been updated to facilitate the clinical management of HIV in low-income settings, where the capacity for sophisticated laboratory investigation remains low.

A person with HIV is defined by WHO as “an individual with HIV infection irrespective of clinical stage, confirmed by laboratory criteria according to country definition and requirements”.¹¹ Once HIV infection has been confirmed, the clinical staging system is used.

The revised clinical staging system is based on a universal four-stage system. This system outlines the clinical criteria and the deﬁnition of symptoms, signs and diseases that determines whether a patient is at clinical stage 1 (asymptomatic), 2 (mild symptoms), 3 (advanced symptoms) or 4 (severe symptoms).¹²

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Table 1 outlines the clinical conditions categorized under the four stages for adults and adolescents.

Conﬁdentiality and security need to guide the collection and reporting of HIV surveillance data.

Clinical staging is important as a criterion for starting antiretroviral therapy.

The global burden of HIV/AIDS

Globally, 33.2 million people carry the HIV virus.¹³ Each year, about 2.5 million more become infected with HIV. Roughly 2.1 million people died of AIDS in 2007.¹⁴ Unknown a quarter of a century ago, HIV/AIDS is now the leading cause of death and lost years of productive life for adults aged 15–59 years worldwide.¹⁵ Table 2 presents a global summary of the HIV/AIDS epidemic in 2007.

Globally, the incidence rate of HIV appears to have peaked in the late 1990s and has begun to stabilize. Because of the relatively stable incidence rate and the continuing high levels of AIDS- related mortality, the HIV prevalence rate appears to be levelling oﬀ since 2001. However, because of population growth and the eﬀect of antiretrovirals (ARVs), the number of people living with HIV is still large.¹⁶

In many parts of the developing world, most new infections occur in young adults, with young women being especially vulnerable. By 2006, roughly 40% of all adults aged 15 years and over living with HIV/AIDS were young people (15–

24 years of age).¹⁷ In sub-Saharan Africa, three women are infected for every two men. Among adults aged 15–44 years of age, the ratio of female to male infection increases to 3:1.¹⁸

More than 2.5 million children are living with HIV.¹⁹ Every year an estimated 2.2 million pregnant women infected with HIV give birth and, about 700 000 of these newborns contract HIV from their mothers.²⁰ In addition, AIDS is compounded by the synergy between HIV and tuberculosis (TB). The spread of HIV has contributed to as much as a fourfold increase in the number of persons with TB in parts of Africa.

More than 10 million people worldwide are infected with both TB and HIV.²¹

The vast majority of people with HIV/AIDS live in sub-Saharan Africa, ands the crisis continues to grow there. In Asia, an estimated 4.9 million Table 2: Global summary of the AIDS epidemic

2001 2007

Number of adults (15+) and children living with HIV

29.0 million

(26.9 million–32.4 million)

33.2 million

(30.6 million–36.1 million) Number of adults (15+) and children

newly infected with HIV

3.2 million

2.5 million

(1.8 million–4.1 million) HIV prevalence in adults (15–49) 0.8%

(0.7%–0.9%)

0.8%

(0.7%–0.9%) Number of adult (15+) and child

deaths due to AIDS

1.7 million

2.1 million

Source: Joint United Nations Programme on HIV/AIDS 2007g.

Table 1: WHO clinical staging of HIV/

AIDS for adults and adolescents with conﬁrmed HIV infection Clinical Stage 1

Asymptomatic

Persistent generalized lymphadenopathy Clinical Stage 2

Unexplained moderate weight loss (<10% of presumed or measured body weight)i

Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media and pharyngitis) Herpes zoster

Angular cheilitis

Recurrent oral ulceration Papular pruritic eruptions Seborrhoeic dermatitis Fungal nail infections

Source: World Health Organization 2006c.

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people were living with HIV/AIDS in 2007.

In the same year, roughly 300 000 adults and children died of AIDS.²² In the Pacific region, an estimated 81 000 people were living with HIV/AIDS in 2006. The HIV prevalence rate in the Pacific was calculated to be 0.4% in 2006.²³ The proportion of adults living with HIV who are women is 29% in Asia and 47% in the Pacific.²⁴

The prevalence of HIV/AIDS in other regions of the world varies considerably, with new infections having declined in Eastern Europe from 230 000

to 150 000 between 2001 and 2007, mainly due to the slower growth of the epidemic in the Russian Federation. In the Caribbean, Latin America, the Middle East and North Africa, North America and Western Europe, the numbers of new HIV infections remained approximately stable between 2001 and 2007.²⁵ Figure 1 depicts the estimated number of people of all ages living with HIV in 2007, by WHO region.

When estimating the prevalence of HIV within countries, a distinction is made between generalized and concentrated epidemics. In a

“generalized epidemic”, the adult HIV prevalence exceeds 1% in the general population and HIV transmission mostly occurs through heterosexual sex. In countries with generalized epidemics, the prevalence of HIV is based on surveillance of pregnant women attending antenatal clinics.

In the absence of population-based surveys that test for HIV antibodies, this approach provides a good proxy of HIV prevalence in the general population. A “concentrated epidemic” is defined as one in which HIV is concentrated in groups of people whose behaviour exposes them to a high risk of HIV infection. Such epidemics are further categorized into concentrated epidemics, where HIV prevalence is measured as consistently over 5% in at least one defined sub-population and low-level epidemics, where HIV prevalence has not consistently exceeded 5% in any defined sub-population. In these countries, the prevalence Figure 1: Estimated number of people living

with HIV (all ages), by WHO region, 2007

Source: Internal data, from database of UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, 2007.

25

20

15

10

5

0 22 400

3 200

530

2 400

4 700

AFR AMR EMR EUR SEAR, WPR

inthousands

Figure 2: HIV prevalence among the general population in Cambodia, 1995–2006 3

2

1

0

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Adult HIV prevalence (%)

Urban Rural Total

Source: Joint United Nations Programme on HIV/AIDS and World Health Organization 2007g.

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of HIV is based on studies of key populations who are at high risk of HIV exposure, such as injecting drug users (IDUs), sex workers, clients of sex workers and men who have sex with men (MSM).²⁶

Many countries in sub-Saharan African are experiencing generalized epidemics. The prevalence of HIV in countries in southern Africa is especially high, with the exception of Angola.

South Africa is the country with the largest number of HIV infections in the world, with an estimated 29% of pregnant women infected in 2006.²⁷

In the Western Paciﬁc Region, generalized epidemics were previously reported in Cambodia and Papua New Guinea. However, in Cambodia the prevalence of HIV has decreased among the adult population. Figure 2 presents HIV prevalence among the general population in Cambodia from 1995 to 2006. In China, Malaysia and Viet Nam, HIV transmission occurs primarily in vulnerable groups, especially sex workers and their clients, MSM and IDUs.

The nature, pace and severity of HIV epidemics diﬀer across the Western Paciﬁc Region. Overall, Asian countries can be divided into several categories, according to the epidemics they are experiencing. While Cambodia, Myanmar and Thailand were hit early, other countries are only now starting to experience rapidly expanding epidemics. These countries include Indonesia, Nepal, Viet Nam, and several provinces in China.

In Myanmar and in parts of India and China, HIV has become entrenched in some sections of the population, despite efforts to halt the spread of the virus. Other countries are still seeing extremely low levels of HIV prevalence, even among people at high risk of exposure to HIV, and therefore have golden opportunities to pre- empt more serious epidemics. These countries include Bangladesh, the Lao People’s Democratic Republic, Mongolia, Pakistan, the Philippines and Timor Leste. In the Pacific, the generalized epidemic in Papua New Guinea contrasts with the very low levels of transmission in other Pacific island nations. Table 3 presents HIV estimations for selected countries in the Western Pacific Region, as of 2007.

Table 3: HIV estimations for selected countries in the Western Paciﬁc Region, 2005

Country HIV estimates in adults (15–49 years)

HIV estimates in women (15–49

years)

AIDS deaths (all ages)

HIV prevalence (%) in adults

Australia 18 000 1 200 <100 0.2

Cambodia 70 000 20 000 6 900 0.8

China 690 000 200 000 39 000 0.1

Fiji <500 <200 <100 <0.1

Japan 9 600 2 300 <100 <0.1

Lao People’s Democratic Republic

5 400 1 300 <100 0.2

Malaysia 79 000 21 000 3 100 0.3

Mongolia <1 000 <200 <100 0.1

New Zealand 1 400 <500 <100 0.1

Papua New Guinea 53 000 21 000 <1 000 1.5

Philippines 8 200 2 200 <200 <0.1

Republic of Korea 13 000 3 600 <500 <0.1

Singapore 4 100 1 200 <200 0.2

Viet Nam 280 000 76 000 20 000 0.5

Note: IDU, injecting drug user; MSM, men who have sex with men; STI, sexually transmitted infection.

Source: Joint United Nations Programme on HIV/AIDS 2008.

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Papua New Guinea, which shares an island with one of Indonesia’s worst HIV-aﬀected provinces, Papua, has the highest prevalence of HIV infection in the Paciﬁc. An estimated 54 000 Papua New Guineans were living with HIV at the end of 2007.²⁸ The number of reported HIV infections was much higher among women aged 15–29 years of age than men of the same age, as Figure 3 shows.²⁹ Young women (15–24 years) appear to be particularly vulnerable, with up to twice as many young women being infected with HIV as men of the same age.³⁰ Available data suggest the epidemic is centred on commercial and casual sex, most of it heterosexual. High HIV prevalence has been found among sex workers (above 10% in the capital, Port Moresby, for example).

HIV infection levels appear to be very low in other countries in the Paciﬁc, but the data are extremely limited. Table 4 presents the latest estimates for the Paciﬁc.

HIV infection levels in Asian countries in the Western Paciﬁc Region are low compared with

countries in other parts of the world, notably those in Africa. But the populations of Asian nations such as China are so large that even low national HIV prevalence rates translate into large numbers of people living with HIV.³¹ The estimated number of people living with HIV in Viet Nam more than doubled between 2000 and 2005.

As of 2005, HIV had been detected in all 64 of Viet Nam’s provinces as well as the major cities.

An estimated 80 000 people were living with HIV in Malaysia in 2007, although the prevalence among women seeking antenatal care remains low (0.4% in 2002). The prevalence rate in Cambodia seems to have declined, following its peak in the late 1990s. The national prevalence rates in China and the Philippines remain well under 0.1%, although, as Table 5 shows, China’s low prevalence rate coupled with its large population translates into a sizeable number of people living with HIV/

AIDS.

In some countries, the means of transmission are changing. In Cambodia, for example, wives of infected men make up nearly half of all new HIV infections; children of infected mothers make up Figure 3: Reported HIV infections by sex, Papua New Guinea, 1987–2006

Male Female Unknown Total HIV Infections by year Source: Government of Papua New Guinea 2007.

Number of infections

Year of diagnosis 0

2000 4000 6000 8000 10000 12000 14000 16000 18000 20000

1987 1988 1989 1990 199 1

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Total

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one third.³² In addition, low national prevalence rates in many countries in the Region mask localized epidemics in diﬀerent areas or vulnerable populations.³³ For example, while HIV has been detected in each of China’s provinces, most reported cases are from Guangdong, Guangxi, Henan, Xinjian and Yunnan.³⁴ Similarly, although the national prevalence rate remains below 0.1%, just under half of people living with HIV are

estimated to have been infected while injecting drugs. HIV prevalence has been found to exceed 50% among IDUs in some areas of Xinjiang, Yunnan and Sichuan provinces.³⁵ The results of sentinel surveillance show that the prevalence of HIV among IDUs was 6.48% in 2004.³⁶ An estimated 89.5% of IDUs dwell in just seven provinces (Guangdong, Guangxi, Guizhou, Hunan, Sichuan, Xinjiang and Yunnan).³⁷ The prevalence of HIV among pregnant women is estimated to range from 0.3% to 1.6% in Yunnan province. In Henan and Xinjiang provinces, HIV prevalence rates above 1% have been observed among pregnant women and women receiving premarital and clinical HIV testing. The epidemic has begun to spread from these vulnerable groups to the general population in some areas in China and Cambodia.³⁸ Among other vulnerable groups, infection rates in men who have sex with men have begun to rise in Cambodia, China, Mongolia and Viet Nam.³⁹

Table 4: HIV and AIDS statistics and features in the Paciﬁc

Number of adults and children living with HIV

Number of adults and children newly infected

HIV prevalence in adults

Number of adult and child deaths due to AIDS

2004 72 000

(44 000–150 000)

8000

(39 000–61 000)

0.3% 2900

(1600–4600) 2006 81 000

(50 000–170 000)

7100

(34 000–540 000)

0.4% 4000

(23 000–66 000)

Source: Joint United Nations Programme on HIV/AIDS and World Health Organization 2006a.

Table 5: Estimated number of people with HIV/AIDS in China

Epidemiological data 2007

Number of adults (15+) living with HIV

690 000 (450 000–1 000 000)

AIDS-related deaths 39 000

(23 000–62 000) Number of women living with

HIV

200 000 (120 000–310 000)

Source: Joint United Nations Programme on HIV/AIDS 2008.

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T

he relationship between HIV/AIDS, poverty and gender is complex. Poor people usually have lower access to health services including those for eﬀective treatment of sexually transmitted infections (STIs), HIV/AIDS prevention and treatment, or prevention of mother-to-child transmission (PMTCT).⁴⁰ In addition, poor people may be less likely to seek health care for opportunistic infections, and may often access health services only in the later stages of the disease, due to various barriers to access to services.

As a result, for a poor person with HIV/AIDS, the time between the ﬁrst presentation at a health care centre and death is often very short.⁴¹

This section discusses these issues. To achieve a better understanding of the relationship between HIV/AIDS, poverty and gender, two lines of enquiry are considered: (1) how poverty- or gender-related factors increase the probability of HIV infection and progression from HIV to AIDS, as well as morbidity and mortality from opportunistic infections; and (2) how AIDS may cause or increase poverty or exacerbate gender inequalities.⁴²

This section begins by considering the relationship between poverty and HIV/AIDS. Box 1 outlines how poverty is conceptualized in this module.⁴³ The links between poverty and HIV/AIDS The relationship between poverty and HIV/

AIDS is multifaceted and likely works along a number of interrelated and overlapping pathways. While many of these pathways remain opaque, it is increasingly clear that the links between poverty and HIV/AIDS can run in both directions. That is, poverty in its multiple dimensions can inﬂuence the likelihood of HIV infection, progression to full blown AIDS, and AIDS-related mortality. This occurs through poor nutrition, limited education and restricted access to appropriate diagnosis, treatment and

care, among other factors. Conversely, people with HIV/AIDS are likely to experience greater poverty as a result of reduced labour productivity when ill and the costs of treatment and care, which may drain the resources of already poor households. The loss of a productive family member to AIDS may reduce household income over the short to medium term with longer- term implications for children in the household, Over the last decades, we have learned that the HIV epidemic is fuelled

by poverty, lack of education and gender inequality.

- Joint United Nations Programme on HIV/AIDS 2002a

Box 1: Deﬁning poverty

In this module, poverty is defined as encompassing not only low income or consumption but also other forms of deprivation, including limited economic opportunities; diminished education and health outcomes; reduced access to services, resources and skills; and voicelessness and powerlessness to influence decisions that affect one’s life. This definition moves beyond a narrow conceptualization of poverty as comprising low income and consumption, which tends to inadequately capture the experience of poverty in the Region. For example, among communities in the Pacific, levels of income or consumption poverty are often low or nonexistent. However, households in the Pacific can be vulnerable to natural disasters; be isolated or remote; lack economic choices (or opportunities to earn a cash income); have limited access to educational, health and financial services; and suffer from social exclusion.⁴⁴

Poverty often overlaps with and reinforces other types of social exclusions such as those based on age, ethnicity, geographical location and gender.

Because of this, communities, households and even members within the same household tend to have diﬀerent experiences of poverty. The poverty experienced in rural communities often diﬀers in important ways from that of urban poor communities, such as slum dwellers. Women within poor households tend to be particularly disadvantaged, as women lag behind men in almost every social and economic indicator of well-being.⁴⁵

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through the intergenerational transmission of poverty. Figure 4 depicts the relationship between poverty and HIV/AIDS.

Figure 4 outlines a number of the pathways through which the links between poverty and HIV/AIDS likely operate. As yet, evidence is insuﬃcient to make the assertion that poverty causes AIDS. However, as the evidence base mounts, the mechanisms through which poverty can increase vulnerability to HIV infection and the progression from HIV to AIDS and AIDS- related mortality are slowly being illuminated. At present, some pathways through which poverty may lead to HIV/AIDS have been demonstrated;

others remain unclear and poorly understood.⁴⁶ At this time, it is probably too simplistic to portray HIV/AIDS as a disease of the poor. For

example, in many countries, the urban elite are the ones purchasing sex, while travelling business people and oﬃcers in the armed forced are having casual sex. These men (and women) are vulnerable to HIV transmission, yet they are not poor.⁴⁷ However, the relationship between poverty and HIV/AIDS is likely dynamic, changing as the HIV/AIDS epidemic in the Region progresses. Improved evidence will likely shed more light on this relationship and the pathways of concern at the household, community and national levels.

Analysis of available data suggests that the relationship between poverty and HIV/AIDS may operate at the global, regional, national and local levels, although this relationship has been more clearly analysed at some levels than at others.⁴⁸ At the local or individual level, the multiple dimensions of poverty, such as lower educational level, fewer livelihood choices, and reduced capacity to negotiate safe sex, probably increase the risk of becoming HIV-infected. For example, as the sections below discuss, evidence suggests that improved education and knowledge of HIV/AIDS can reduce the probability of HIV infection. Once infected, economic and social costs may delay seeking diagnosis, treatment and care for HIV/AIDS and may increase the likelihood of progression from HIV infection to AIDS, as well as of death from opportunistic infections.

In most countries in the Region, the epidemic is largely concentrated within marginalized groups which, while not always income- or consumption- poor, are likely to experience discrimination that can heighten their vulnerability to HIV/AIDS.

Globally, the distribution of HIV/AIDS has been positively associated with absolute poverty.⁴⁹ The sections below outline the evidence on the ways in which poverty can increase the likelihood of HIV infection and progression to AIDS and AIDS-related mortality. The section begins with an overview of the association between poverty and HIV at the global, national and local levels.

Figure 4: The relationship between poverty and HIV/AIDS

Source: Adeyi et al. 2001.

HIV/AIDS Poverty

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The eﬀect of poverty on HIV infection

Developing countries are home to an estimated 85% of the global population and more than 95%

of HIV-infected people.⁵⁰ Sub-Saharan Africa, which bears the brunt of the global HIV/AIDS epidemic, has the lowest gross national product (GNP) of any region in the world.⁵¹ Analysis of cross-country evidence has revealed a signiﬁcant positive association between high HIV prevalence and low socioeconomic performance. This relationship was found to hold true regardless of the measure of socioeconomic performance used, be it per capita income, income inequality, absolute poverty or the UNDP Human Poverty Index.⁵² While the association between poverty and HIV appears to have been demonstrated at the global level, the picture at the regional and national levels remains less clear. A study of poverty and HIV concluded that no clear relationship exists between poverty and national rates of HIV in any continent, including Asia. The notable exception was Africa, which reported a negative correlation between socioeconomic status and HIV.⁵³ A study in 1999 found that the prevalence of HIV was higher among people who were better educated and wealthier than among those who were poor and less educated.⁵⁴ The results of more recent research suggest that this negative association between HIV and poverty in Africa may have lessened. Analysis of population survey data carried out in 2006 concluded that no correlation exists between education level and HIV status.⁵⁵ Initially, HIV may disproportionately aﬀect people who were wealthy and well educated.

However, the growing consensus is that, as the epidemic progresses, the incidence of HIV becomes increasingly concentrated in poor and marginalized populations.⁵⁶ In addition to the evidence cited from the African region, this assertion is supported by evidence from Brazil. In the early 1980s, an estimated 75% of people who were newly diagnosed with HIV in Brazil had a secondary education or higher. By the early 1990s, this proportion fell to roughly one third.⁵⁷ This also seems to be the case in developed countries,

where poor and marginalized communities bear a disproportionate burden of HIV.⁵⁸ Over time, it is expected that wealthier and better educated populations will be able to protect themselves better from HIV infection and will have greater access to technological innovations, such as ART, which will enable them to lead productive and healthy lives. In contrast, poor populations, which tend to have less access to information and appropriate treatment and care for HIV/AIDS, will be unable or unwilling to protect themselves from HIV infection because of hardship and destitution.

Notwithstanding the lack of a statistically significant (positive or negative) association between national HIV prevalence rates and poverty in Asia, a brief review of available data suggests that the burden of HIV/AIDS in the Western Pacific Region is largely concentrated among developing countries. Papua New Guinea and, previously Cambodia, the two countries with generalized epidemics in the Region, are classified as low-income economies.⁵⁹ The prevalence of HIV is expanding rapidly in other low- and lower- middle-income economies in the Region, such as Viet Nam and China. To date, the prevalence rate in upper-middle-income economies, such

Box 2: Populations vulnerable to HIV/AIDS People living in poverty

People with low levels of education People living in remote regions Women

Ethnic minorities Youths and infants Sex workers Infecting drug users

People engaged in skin piercing, e.g. tattoos Blood donors and recipients of blood or organ transplants

Prisoners or people in other types of closed settings Refugees

Migrant workers

Military and police personnel

Internally displaced populations (due to war, famine, earthquake, other natural disasters, civil unrest, etc.)

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as Malaysia and the Philippines, has remained relatively low.

A number of countries in the Region are experiencing localized epidemics in certain geographical areas, vulnerable populations and specific age groups. For example, seven of the 10 provinces in China with a high prevalence rate of HIV are located in the economically underdeveloped central and western regions.⁶⁰ Box 2 lists populations that have been identified as being particularly vulnerable to HIV/AIDS, although the vulnerability differs across the different groups.

Often, discussion of HIV infection in these populations focuses on the role of high-risk behaviours in the transmission of the virus.

Focusing on individual behaviour obscures the fact that people act within a context that is shaped by economic, political and cultural elements within a society, which can increase the vulnerability of some people to HIV infection.⁶¹ For example, poverty may reduce an individual’s ability or willingness to take actions considered necessary to avoid infection. Poverty may also increase the likelihood that people will engage in high-risk occupations, such as sex work. Poverty is further

associated with lower educational attainment, which in turn is linked with lower awareness of eﬀective measures to prevent HIV infection.⁶² Figure 5 presents various ways in which poverty can be understood to lead to increased risk of HIV infection.

A growing body of evidence conﬁrms the links between poverty and HIV infection at the household (micro) level. The sections below consider various pathways through which poverty can increase the vulnerability of individuals to HIV/AIDS infection.

Low household income

Studies from a number of countries in Asia have reported an association between low household income and increased likelihood of HIV infection.

For example, research carried out in Thailand found that people from the poorest households in the study population were the most likely to be infected with HIV.⁶³ Similarly, in India, low household socioeconomic status signiﬁcantly contributed to the likelihood of people being infected with HIV.⁶⁴ Low household income was also associated with increased risk of infection in Sri Lanka.⁶⁵ Similarly, household income has been Figure 5: Poverty increases the likelihood of HIV infection and AIDS

Source: Adeyi et al. 2001.

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positively correlated with reduced risk factors for HIV, such as increased awareness of modern contraceptives and the beneﬁt of condoms, in Cambodia and Viet Nam.⁶⁶ Evidence suggests that women’s awareness of HIV prevention methods improves as household income rises in Cambodia, the Philippines and Viet Nam (Figure 6);

men’s awareness also improves in the Philippines (Figure 7).

While these data suggest that the protective effect of higher household income may operate through improved education and knowledge of HIV, further analysis of the Cambodian and Vietnamese data concluded that household income and education also have independent effects on reduced risk factors for HIV. This may be because people living in poor households are less able to afford preventive measures, such as condoms.

Similarly, low household income may be associated with many of the other factors outlined below.

Geographical location

In many countries in the Region, poverty is largely concentrated in rural communities. The percentage of the poor residing in rural areas is 90% in Cambodia, 94% in the Philippines and 74% in Viet Nam.⁶⁷ In the Lao People’s Democratic Republic, the poverty rate in urban

areas was estimated at 27%, compared with 41%

in rural areas.⁶⁸

The burden of HIV in countries in the Region may be unevenly distributed between urban and rural areas. In some countries, IDUs, sex workers and MSM, among other populations vulnerable to HIV, tend to reside in urban rather than rural areas. However, according to the World Bank, because the populations of many developing countries remain largely rural, the number of people living with HIV may actually be higher in rural areas.⁶⁹ China’s experience of HIV may be unique, in that the epidemic spread from rural to urban areas. An estimated 70% of people infected with HIV in China live in rural communities.⁷⁰ Notably, in China, transmission in the early stages of the epidemic occurred mostly through faulty plasma collection procedures. High rates of STI have been reported in rural and remote communities in some Paciﬁc island countries. In Papua New Guinea, for example, a study estimated that 59% of women in a small village in Asaro Valley in the Eastern Highlands Province had an STI in 1998.⁷¹ Interestingly, a study found HIV prevalence to be twice as high among sex workers in a rural province in Cambodia as among sex workers in Phnom Penh. The study suggested that the comparatively older age of sex workers in rural areas may have resulted in higher rates of HIV.⁷² Figure 6: Proportion of women aged

15–49 years who know at least one way to avoid sexual transmission of HIV by income quintile, in Cambodia (2000), the

Philippines (2003) and Viet Nam (2002)

Source: Gwatkin D. et al. 2007a, b and c.

Percentage

100 90 80 70 60 50 40 30 20 10 0

Lowest Second Middle Fourth Highest Cambodia Philippines Viet Nam

Figure 7: Proportion of men aged 15–54 years who know at least one way to avoid sexual transmission

of HIV, by income quintile, in the Philippines

Source: Gwatkin et al. 2007b.

Percentage

100 90 80 70 60 50 40 30 20 10 0

Lowest Second Middle Fourth Highest

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In countries where the incidence of HIV has clustered in urban areas, it is possible that rural communities are uniquely vulnerable to HIV transmission. This vulnerability is likely a result of the generally poor coverage of health care facilities in rural areas and inadequate prevention and surveillance eﬀorts. In addition, migration patterns and the tendency for HIV- positive people in urban areas to return to their rural communities when they fall ill will tend to inﬂuence the shape of the HIV epidemic in rural communities.

Knowledge and awareness of HIV/AIDS has also been found to be lower among rural communities.

A study of knowledge of HIV/AIDS among college students attending university in Beijing and Nanjing, China, concluded that students from urban areas had signiﬁcantly higher levels of knowledge of HIV than those from rural areas.⁷³ The proportion of women aged 15–49 years who knew at least one way to avoid the sexual transmission of HIV was calculated to be 86% in urban areas as compared with 71% in rural areas of Cambodia. Similarly, women of the same age group in urban areas were more likely to know that HIV/AIDS can be transmitted from mother to child than were women from rural areas (85.3%

vs. 69.6%).⁷⁴ A similar pattern was observed in the Philippines and Viet Nam.⁷⁵ In the Philippines, the proportion of men aged 15–54 years who used a condom the last time they had sex with a non- regular partner was found to be 31.0% in urban areas and 28.6% in rural areas in 2003.⁷⁶

Lower educational status

Poor people often have lower levels of education and less access to educational messages about HIV than those who are better-oﬀ. There is growing evidence that lower educational status and illiteracy lead to a lack of awareness about HIV/AIDS and its modes of transmission.⁷⁷ In Bangladesh, Nepal and Viet Nam, knowledge that condoms can prevent the transmission of HIV was found to be positively correlated with educational attainment.

Women with no education were signiﬁcantly less likely than those with primary school education to know about the preventive eﬀect of condoms, while women with even higher levels of education had the greatest awareness.⁷⁸

Lower awareness of HIV/AIDS has, in turn, been linked with an increased likelihood of risky behaviour. A study in Thailand observed that men with a good understanding of appropriate prevention strategies and the mechanisms of infection were less likely to frequent sex workers than men who had a weak understanding of these issues. A poorer understanding of HIV prevention and transmission was more common among men of lower socioeconomic status.⁷⁹ Table 6 presents the ﬁndings of a study on the links between poverty, low education and risk-taking behaviour in Viet Nam.

The ﬁndings suggest the potentially powerful protective eﬀect of education. For example, high school or higher education attainment Table 6: Poverty, low education and risk-taking behaviour in Viet Nam

Wealthiest income quintile (Number of times more likely to be aware of prevention measures compared to those in lower income brackets)

Highest education

(Number of times more likely to be aware of prevention measures compared to those with lower education levels)

Condom use 2.684 6.455

Having only one sex partner 1.959 4.144

Avoiding sex with sex workers 2.233 0.967

Knowledge of source of condoms 2.175 34.132

Knowledge about condoms 2.504 26.720

Source: Bloom et al. 2001:14 In: Australian Agency for International Development and United Nations Development Programme 2005.

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was associated with a lower prevalence of HIV among injecting drug users in Long An Province, Viet Nam, in 2002.⁸⁰ However, even when information about HIV/AIDS reaches poor individuals, they may not understand the messages or may not perceive the risk to be important within their day-to-day struggle for survival and thus, may fail to take preventive measures.⁸¹

Restricted choice of safe economic activities The income-earning opportunities available to poor people are often restricted by their low levels of education and skills. Faced with limited economic opportunities, the short-term survival needs of poor men and women and their families may lead to the adoption of a range of coping strategies with negative implications for their health and well-being in the medium or longer term.⁸² This includes income-earning activities that may increase the risk of poor men and women to HIV infection. For example, while women engage in commercial sex for a variety of reasons, many sex workers are likely to be poor. A study carried out in Siem Reap, Cambodia, found that 51.4% of female sex workers had never attended school.⁸³

While a range of income-earning opportunities may increase the vulnerability of poor men and women to HIV infection, much attention has been devoted to the role of migration in the transmission of HIV in the Region. Men and women migrate for a range of reasons.

Some migrate in search of improved economic opportunities, while others are tricked or forced into migrating. The vulnerability of economic migrants to HIV infection may differ from those who are forced to migrate or are trafficked. On the other hand, in some cases, the vulnerability of poor economic migrants who have few opportunities, or those who are undocumented in their area or country of residence, may not differ substantially from those who are trafficked.

Work-related migration might take place within the country (internal) to rural or urban areas or outside the country of origin.

The positive relationship between migrant labour ﬂows and the spread of HIV is quite strong.

Evidence shows that migrants have higher rates of HIV than non-mobile populations, regardless of the HIV prevalence rates at the source or destination sites.⁸⁴ A number of factors that contribute to the spread of HIV among labour migrants have been identiﬁed. Of particular importance are: length of time away from the social norms of the migrant’s home environment;

accommodation with members of the same sex;

constrained access to reproductive health services;

loneliness- and boredom-induced alcohol and drug abuse; and “a dysfunctional symbiosis between migrant labour and sex work”.⁸⁵ For example, a study in Sichuan province, China, reported that migrant workers constituted the majority of men purchasing sex from female sex workers. On average, migrant workers were found to have bought sex 11 times during the previous six months and the majority (64%) had not used a condom the last time they paid for sex.⁸⁶ A study was carried out in 1998 among ﬁrst-time departing migrant workers in the Philippines to identify the factors that increased their vulnerability to HIV/

AIDS. The ﬁndings suggest that vulnerability to HIV/AIDS among Filipino migrant workers was linked to low knowledge of HIV/AIDS, limited condom use, poor health-seeking behaviour and a sense of invincibility towards HIV/AIDS. In addition, the study noted that the general neglect of issues such as loneliness, cultural adaptation and possibly diﬃcult working conditions among the study population may have also contributed to their vulnerability.⁸⁷

The following examples, including those from the Region, point to the links between mobility and HIV/AIDS:⁸⁸

Migrant workers

t : Of the Filipinos reported to be living with HIV, 33% were migrant workers who have returned home. Roughly 75% of these workers were men.⁸⁹ About 41% of HIV-positive Bangladeshis were migrant workers. In Shanghai, China, an estimated 60% of people infected with HIV are migrants.⁹⁰